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Global Journal of Anesthesiology eertechz
Citation: Bhansali GC, Solanki SL (2015) Placenta Previa
Combined with Placenta Accreta and Fetal Congenital High Airway
Obstruction- Failed Ex Utero Intrapartum Treatment. Glob J
Anesthesiol 2(2): 057-059.
057
within normal limits. Blood pressure was 110/80 mmHg and heart
rate was 82/minute. Airway examination revealed mouth opening of 3
cm. She was mallampatti class II with full range of neck movement.
Tablet ranitidine 150 mg and metoclopramide 10 mg was given night
before surgery and in morning on day of surgery. In the operating
room, standard 5 leads ECG, NIBP and pulse oximetry were attached
and baseline parameters were noted. Two large bore (16 G) venous
cannulae were secured in upper limbs and normal saline infusion was
started. ENT and pediatric surgeons were kept ready for surgery and
procedures on baby. After preoxygenation with 100% for 5 minute
(target endtidal oxygen >90%), rapid sequence anesthesia was
induced with IV thiopentone 325 mg and IV suxamethonium 125 mg.
Trachea was secured with 7.0 mm ID tracheal tube. IV atracurium 25
mg was given once the effect of suxamethonium was tapered.
Anesthesia was maintained with isoflurane in a mixture of oxygen
and nitrous oxide (30:70). Right internal jugular central venous
catheterization was done and radial artery was cannulated for
continuous invasive blood pressure monitoring. Surgical plan was to
perform ex utero intrapartum treatment (EXIT) on fetus after
classical cesarean incision if the maternal bleeding will be under
control. Surgery was allowed to start. Uterus was opened and baby
was delivered out. As soon as the baby was delivered profuse
bleeding was started from uterus and placenta. It was decided not
to perform EXIT procedure and cord was clamped and cut. Bleeding
was continued from uterus and placenta. Three units of packed red
blood cells and three units of fresh frozen plasma were transfused.
Meanwhile ENT surgeon performed tracheostomy on baby and airway was
secured but baby died after half an hour. All measures to control
the bleeding were failed. Bleeding was continued from uterus and
placenta, hysterectomy was done. Blood loss was around 2500
IntroductionPlacental abnormalities like placenta previa and
accreta are more
common in parturient with prior history of cesarean delivery.
They are prone to cause massive bleeding during cesarean and
emergency cesarean hysterectomy has to be performed to save the
life of mother. If such a condition is associated with fetal airway
abnormalities then condition may be even worse. We here describe a
case of parturient with placenta previa-accreta and fetal
congenital high airway obstruction posted for cesarean section.
Case ReportA 26 year old G2P1001 parturient was admitted at 32
weeks of
pregnancy for obstetric services. She was a diagnosed case of
placenta previa grade III with placenta accreta. Ultrasonography
(USG) at 16 weeks of pregnancy showed normal fetal skull, spine and
stomach. At 26 weeks of pregnancy USG showed low lying placenta
anteriorly covering internal os, moderate to severe fetal
hydrocephalus with dilated lateral ventricles (1.9 cm), single
upper limb and short other limbs, skeletal dysplasia and
over-distended fetal abdomen with large cystic masses. Level II
obstetric USG at 28 weeks showed fetal congenital high airway
obstruction and free fluid in fetal abdomen. In her last pregnancy
a singleton healthy male baby was delivered by elective cesarean
section for breech presentation. She was hypothyroid since 3 years
and was taking tablet thyroxine sodium 100 mcg once a day. No other
comorbidities were present. On examination she was 65 kg in weight
and 156 cm in height. Cardiovascular and respiratory system
examination revealed no abnormality. Her complete haemogram showed
haemoglobin of 10.2 gm/100 ml, total leucocyte count of 7400/mm3
and platelet of 202000/mm3. Her thyroid functions, liver functions,
renal functions and coagulogram were
Case Report
Placenta Previa Combined with Placenta Accreta and Fetal
Congenital High Airway Obstruction- Failed Ex Utero Intrapartum
Treatment
Gautam Chand Bhansalil and Sohan Lal Solanki2*
1Assistant Physician, Department of Medicine, Bombay Hospital
and Medical Research Centre, Mumbai-India2Assistant Professor,
Department of Anaesthesiology, Critical Care and Pain, Tata
Memorial Hospital, Mumbai-India
Dates: Received: 12 November, 2015; Accepted: 08 December, 2015;
Published: 10 December, 2015
*Corresponding author: Dr. Sohan Lal Solanki, Department of
Anesthesiology, Critical Care and Pain,2nd Floor, Main Building,
Tata Memorial Hospital, Parel, Mumbai-India, Tel: +91-9969253201;
E-mail:
www.peertechz.com
Keywords: EXIT; Placenta previa; Placenta accrete; CHAOS
Abstract
A parturient with placenta previa and accreta combined with
fetal congenital high airway obstruction was scheduled for cesarean
section. Ex utero intrapartum (EXIT) treatment on fetus after
classical cesarean section was planned. General anesthesia was
induced after routine and invasive haemodynamic monitoring started.
Profuse bleeding was started as soon as the baby was delivered.
EXIT procedure was cancelled and cord was clamped and cut. ENT
surgeon performed tracheostomy on baby and airway was secured but
baby died after half an hour. Emergency cesarean hysterectomy was
done after all measures to control the bleeding were failed.
-
Citation: Bhansali GC, Solanki SL (2015) Placenta Previa
Combined with Placenta Accreta and Fetal Congenital High Airway
Obstruction- Failed Ex Utero Intrapartum Treatment. Glob J
Anesthesiol 2(2): 057-059.
Bhansali et al. (2015)
058
ml. Patient was electively mechanically ventilated for 12 hours
in post anaesthesia care unit with close monitoring. Trachea was
extubated once the patient becomes conscious and her arterial blood
gases were within normal limits. Post-operative course of mother in
PACU and ward was uneventful and she was discharged from hospital
on 7th post-operative day.
DiscussionPlacenta praevia is a major cause of maternal
obstetric
haemorrhage. If placenta praevia is complicated by accreta and
percreta the risk is even higher. As a result of the increasing
number of surgical deliveries incidence of these conditions are
rising [1,2]. Placenta accreta occurs most frequently in women with
one or more prior cesarean deliveries who have a placenta previa in
the current pregnancy. According to Clarke et al. [3], in the
presence of a placenta previa, the risk of having placenta accreta
increased from 24% in women with one previous cesarean section to
67% in women having 3 or more cesarean sections. Hysterectomy is
still main treatment to control the bleeding in these conditions
with higher maternal morbidity and mortality.
Massive obstetric hemorrhage as a result of placenta previa and
accreta may result into complications as injury to the ureters,
urinary bladder, and other abdominal viscera, disseminated
intravascular coagulopathy, acute lung injury, adult respiratory
distress syndrome, acute renal failure, and even mortality [4].
Placenta accreta is one of the leading reason for cesarean
hysterectomy [5]. Minor placenta accreta may lead to slightly
heavier postpartum bleeding, but may not require hysterectomy but
extensive placenta accreta often require. The standard management
of these conditions is to leave the placenta in situ, with no
attempt at removal. Hysterectomy can be performed 2 to 6 weeks
later on an elective basis. Pelvic arterial embolization or balloon
catheter occlusion significantly reduces uterine blood flow and
allow reduced blood loss during surgery [6]. Other adjunctive
procedures like methotrexate therapy, uterine compression sutures,
internal iliac vessels embolization, resection of the affected
segment of the uterus and oversewing of the placental bed may help
[7-9].
Congenital high airway obstruction syndrome (CHAOS) is an
ultrasonographic antenatal diagnosis comprising extremely large
echogenic lungs, pleural or pericardial effusions, a dilated
tracheobronchial tree, inverted or flattened diaphragms, fetal
ascites with nonimmune hydrops and complete or almost complete
upper airway obstruction [10-14]. These findings result from
increased intratracheal pressure and distention of the
tracheobronchial tree secondary to the accumulation of fluid in the
lungs. Laryngeal atresia, laryngeal web, laryngeal cyst or tracheal
atresia may be the causes of airway obstruction. The incidence of
CHAOS is rare [10]. Skeletal and vertebral malformations,
tracheoesophegeal fistula, esophageal atresia, genitourinary
malformations, limb deformities and cardiac malformations are
usually associated with CHOAS.
The EXIT procedure during cesarean section requires specific
anesthesia considerations and techniques and ultimate goal is a
healthy mother and infant. The success mainly depends on a
well-planned an aesthesia technique. The EXIT procedure, in
contrast to a routine cesarean section, mandates proper uterine
relaxation
before uterine incision with the use of high concentration of
inhaled anesthetic agents [15]. Complete uterine relaxation is
required for delivering the fetal head, shoulders, and if there is
any large neck mass or goiter in fetus which are normally unable to
pass through a normal lower segment uterine incision. Uterine
perfusion is main determinant of fetal oxygenation and has to be
maintained by proper uterine relaxation. Also the procedure on
fetus requires time and during this period fetus needs inhalational
anesthesia via transplacental transfer. Complete uterine relaxation
places the mother at risk for massive intraoperatively bleeding
from placenta and uterus. Also high concentration of inhaled
anesthetic causes more hypotension intraoperatively from profound
vasodilatation and if not treated timely and promptly, causes fetal
hypoxia from decreased uterine perfusion. Short-term maternal
outcomes do not differ between those patients receiving EXIT
procedures and those patients undergoing cesarean sections if not
associated with any placental abnormality.
In our case fetal CHAOS was associated with maternal previa and
accreta. Placenta was low lying and covering internal os. The
surgical plan was to perform the classical cesarean section under
deep plane of general anesthesia and EXIT procedure (fetal
tracheostomy) was planned by ENT surgeons after delivering the
fetus through classical cesarean incision. Unfortunately, after
uterine incision, there was profuse bleeding from uterus and the
whole surgical field was bloody. EXIT procedure was cancelled and
fetal tracheostomy was done on fetal table. Maternal blood pressure
also became low and ephedrine boluses were given to maintain the
maternal haemodynamics. Immediately inhaled anesthetics
concentration was reduced and blood products were transfused. All
measures to control the bleeding were failed and emergency cesarean
hysterectomy was done. Blood loss was around 2500 ml.
Even after thorough search, we did not encounter any study or
reported case presenting EXIT procedure in fetus with maternal
placenta previa and accreta. Massive maternal bleeding in our case
may be due to the deep plane of inhaled anesthesia in addition to
the maternal placental abnormalities. Also by classical cesarean
incision, mostly the placental site can be avoided, but in our case
even after classical incision, bleeding was profuse and even
experienced senior gynecologist failed to control the bleeding.
The aim of the present case is to highlight the possible risk to
maternal health if CHOAS or any fetal airway abnormalities are
associated with placental abnormalities. Yet more discussion and
modalities require if EXIT procedure has to be performed for saving
the infant.
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Citation: Bhansali GC, Solanki SL (2015) Placenta Previa
Combined with Placenta Accreta and Fetal Congenital High Airway
Obstruction- Failed Ex Utero Intrapartum Treatment. Glob J
Anesthesiol 2(2): 057-059.
Bhansali et al. (2015)
059
Copyright: © 2015 Bhansa GC, et al. This is an open-access
article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and
source are credited.
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TitleAbstractIntroductionCase Report DiscussionReferences